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Application for Fellowship

This application must be submitted typed. Please fill in the fields, print and mail to the AGPA office.

Name
Degree
CGP Yes   No
Street address
Address (cont.)
City
State
Zip
Work Phone
Home Phone
Fax
E-mail
Date of AGPA Clinical Membership: -- mm/dd/yy
If applicable, date of last application for Fellowship: -- mm/dd/yy
FELLOWSHIP REQUIREMENTS

FELLOWS:
a. Rights and Privileges. Fellows shall enjoy all the rights and privileges of members in good standing.

b. Qualifications. Members of the Association in good standing 1) who have been Clinical Members for five years, unless this requirement is waived by unanimous vote of the Board of Directors; and 2) whose outstanding performance in the field of group psychotherapy has been demonstrated by leadership in organizational service as well as excellence in one of the following areas: II-A) Clinical Practice and Administration; II-B) Teaching; II-C) Research; and II-D) Publications.

I. General Leadership (if additional space is needed, please attach a separate sheet):

A.  Offices Held   

Offices Held

Organization

Date(s)

B.  Committee/Task Force Participation 

Chair/Member/AGPA Representative (Specify Role and Committee) Organization Date(s)

 C. Promotion of Group in Other Domains (Government, Industry, Education, etc.)

Activities (Describe)

Organization

  Date(s)

 
D. Group Therapy Related Awards and Honors

Name of Award

Organization

  Date(s)

 
E.  Group Psychotherapy Presentations at Professional Meetings

     (Identify type of presentation: Institute, Workshop, Seminar, Core   

       Course and List Title)

 

Presentation

Length of Presentation

Organization

 Date(s)
       
       
       
       
II. Please identify ONE additional category cited below for which you have demonstrated excellence and list these specific activities with associated dates on a separate sheet using the format outlined for previous items.

A.  Clinical Practice and Administration  B.  Teaching and Training* 

C.  Research  D. Publications

* Activities reported in category I (General Leadership) may not be duplicated in category II-B (Teaching and Training)--choose one.

III. Please identify any additional experience which you would like the Fellowship and Awards Committee to consider.


IV. Names and addresses of two fellows of AGPA who have agreed to endorse your application (please append letters of reference to the application).
1. Name
Street address
Address (cont.)
City
State
Zip
2. Name
Street address
Address (cont.)
City
State
Zip

 

V. Please send a copy of your curriculum vitae with this application. Information on the curriculum vitae will not be accepted as a substitute for completing the above information; it is an addendum to the application.

 Date: -- mm/dd/yy

Applicant Signature:

  Please send completed form-in duplicate-and attachments to

AMERICAN GROUP PSYCHOTHERAPY ASSOCIATION, INC.

25 East 21st Street, 6th Floor, New York, NY 10010